Provider Demographics
NPI:1235289679
Name:HABTEZGHI, HAGOS (MD)
Entity Type:Individual
Prefix:DR
First Name:HAGOS
Middle Name:
Last Name:HABTEZGHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3334 HEATHER FIELD DR
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6137
Mailing Address - Country:US
Mailing Address - Phone:323-835-8401
Mailing Address - Fax:
Practice Address - Street 1:9901 COMPTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-2850
Practice Address - Country:US
Practice Address - Phone:323-835-8401
Practice Address - Fax:323-835-8405
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC41500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE48010Medicare UPIN